David Kerr: UK and US healthcare- public option is the universal, high quality, and efficient way

September 21, 2009

Writers of the open letter to America in defence of the NHS rebut clearly and concisely some of the more ludicrous charges leveled against our system of healthcare. It’s a debate that on the whole leaves me cold. The idea that wittingly a Government would allow a huge chunk of its population to go without proper healthcare is unfathomable to me.

Underlying the discussion, however, is an assumption that for those who can afford health insurance, the US system is better than ours could ever be.

That’s a false assumption. Simply spending more money on healthcare does not mean you will get better healthcare.

In America, as health care costs spiral out of reach of many ordinary families, we have an extreme example. The more expensive provision becomes, the fewer people benefit (46 million at last count). A 17% spend of GDP on health has not delivered the promised land.

In the UK we spend 8% of GDP. It’s universal and 80% of the people who use the NHS are satisfied with it. There are financial lessons there to be learnt, if America wants to learn them.

In particular the US should look at the strength of our primary care system. In America, primary care is an area of relative weakness. GPs are paid far less than their specialist counterparts. Not surprisingly, there are far fewer of them and this has far reaching consequences. Specialists rule the roost and they maintain
their high incomes by deploying ever more expensive and complex diagnostic tools, drugs, and surgical procedures, sometimes unnecessarily. The effect? Higher health care costs for all.

In the UK, on the other hand, GPs are the first port of call for most concerns. GPs deal with the whole person and only refer patients to a specialist when they really need to go. GPs in the UK effectively absorb diagnostic risk and patients, trusting in their doctors, give them the power to do so. It’s good for the patient and good for the NHS as it keeps costs down without jeopardizing patient care.

Healthcare rationing is a second area where the US could learn from the UK. If the US is going to reform its system to include an element of universal care America will have to shift radically its concept of health care rationing from ability to pay to value for money.

The UK already rations care on that basis, difficult as it may be. Not every single medical advance can be approved by NICE regardless of how marginal the benefits. But the system is transparent, evidential, and
rule based and certainly not based on the amount of insurance cover an individual has. It may not be perfect but it is fit for purpose and America will have to adapt some kind of similar model if reform is to
succeed.

An enormous part of the American health care debate has focused on how to fund expanded healthcare provision. The NHS has been the bogeyman of the debate with individual and tragic examples of failure – which occur in every system – being hauled in front of the world’s media to make a case against a public option.

America can learn from the NHS not just in terms of the ethical principle of universality but also in terms of financial control. If Senator Baucus’ new legislative proposals are anything to go by these lessons need to be learnt fast before the public option slides irrevocably towards the exit of the US healthcare debate. America should introduce a cost curbing, high quality competitive public option and watch premiums tumble. This is the surest route to nearer universality.

Professor David Kerr is Chief Research Advisor, SIDRA; Director, Qatar Biomedical Research Institute and Professor of Cancer Medicine, Oxford University.

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